A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Administer intravenous pain medication.

Draw blood for a complete blood cell (CBC) count.

Insert an indwelling urinary catheter.

Inspect the mouth for signs of inhalation injuries.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This choice is incorrect because administering intravenous pain medication is not the priority action for a client who has sustained partial-thickness burns. Pain medication may be indicated for pain relief and comfort, but it does not address the potential life-threatening complications of burns such as shock, infection, or respiratory distress.

Choice B Reason: This choice is incorrect because drawing blood for a CBC count is not the priority action for a client who has sustained partial-thickness burns. A CBC count may be useful to monitor the hematological status and detect any signs of infection or anemia, but it does not address the immediate needs of the client

Choice C Reason: This choice is incorrect because inserting an indwelling urinary catheter is not the priority action for a client who has sustained partial-thickness burns. A urinary catheter may be necessary to measure the urine output and assess the renal function and ﬂuid balance, but it does not address the most urgent problem of the client.

Choice D Reason: This choice is correct because inspecting the mouth for signs of inhalation injuries is the priority action for a client who has sustained partial-thickness burns. Inhalation injuries are caused by inhaling hot air, smoke, or toxic gases that damage the airway and lungs. They can cause airway obstruction, bronchospasm, pulmonary edema, or respiratory failure. Therefore, the nurse should inspect the mouth for signs such as soot, singed nasal hairs, burns on the lips or tongue, hoarseness, stridor, or wheezes. The nurse should also monitor the oxygen saturation and arterial blood gases to assess the oxygenation and ventilation status of the client.

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Correct Answer is D

Explanation

Choice A Reason: This choice is incorrect because warm, ﬂushed skin is not a sign of respiratory acidosis. Warm, ﬂushed skin may indicate fever, infection, inﬂammation, or allergic reaction, but it does not reﬂect the acid-base imbalance in the blood.

Choice B Reason: This choice is incorrect because hyperactive deep tendon reﬂexes are not a sign of respiratory acidosis. Hyperactive deep tendon reﬂexes may indicate hypocalcemia, hyperthyroidism, or spinal cord injury, but they do not reﬂect the carbon dioxide level in the blood.

Choice C Reason: This choice is incorrect because bounding peripheral pulses are not a sign of respiratory acidosis. Bounding peripheral pulses may indicate increased cardiac output, anxiety, or hyperthyroidism, but they do not reﬂect the pH level in the blood.

Choice D Reason: This choice is correct because widened QRS complexes are a sign of respiratory acidosis. QRS complexes are the segments on an electrocardiogram (ECG) that represent the depolarization of the ventricles. A normal QRS complex duration is 0.06 to 0.10 seconds, and a widened QRS complex duration is more than 0.12 seconds. A widened QRS complex may indicate hyperkalemia, which is a common complication of kidney failure and respiratory acidosis. Hyperkalemia is a condition in which the serum potassium level is higher than normal (more than 5 mEq/L). It may cause cardiac arrhythmias, muscle weakness, or paralysis.

Correct Answer is ["100"]

Explanation

To estimate the percentage of body surface area burned using the Rule of Nines, follow these guidelines:

Head and Neck: 9%
Each Arm: 9% (right arm) + 9% (left arm) = 18%
Front of Torso: 18%
Back of Torso: 18%
Each Leg: 18% (right leg) + 18% (left leg) = 36%
Genital Area: 1%

Now, add up the percentages of the burned areas:

9% (head and neck) + 18% (each arm) + 18% (front of torso) + 18% (back of torso) + 36% (each leg) + 1% (genital area) = 100%

So, the nurse should estimate that the client has burned 100% of their body surface area.

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A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is ["100"]

Explanation

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